UNDERSTANDINGCHANGE

Updated 07-06-13

SERENE.ME.UK/HELPERS/

#SERENITYPROGRAM

FACEBOOK.COM/SERENITY.PROGRAMME

2This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 3.0 Unported License.

SERENE.ME.UK/HELPERS

#SERENITYPROGRAM

SERENITY.PROGRAMME

Contacts

3

• Types of change• Prerequisites for change• Typical reactions to change• Communicating to different audiences• Organisational learning – learning to learn• Effectiveness of change methods• Cautionary tales – Ferlie & Fitzgerald• Models of the organisation• Prochaska & DiClementes’ model

Change

4

Change - Intentionality

May be Planned or Emergent:

• Planned – the product of conscious reasoning and action

• Emergent – Change unfolds in an apparently spontaneous and unplanned way – non-linear & uncontrolled

[Note that intentional change oftenhas important emergent effects!]

5

Change - Temporality

May be Episodic or Continuous:

• Episodic – infrequent, discontinuous and intentional

• Continuous – ongoing, incremental, evolving and cumulative

6

Change - Depth

May be First, Second or Third Order:

• First Order (Alpha change) – Minor adjustments in structure or process

• Second Order (Beta Change) – Major reviews of underlying structure or processes

• Third Order (Gamma Change) – Paradigmatic shift – complete revision

7

Change – Scope & Extent

May be Developmental, Transitional or Transformational:

• Developmental – 1st order, either planned or emergent, incremental change that either realigns or enhances existing resources

• Transitional – Episodic, planned, 1st/2nd order, seeks to achieve a known desired state

• Transformational – 2nd/3rd order, paradigmatic change

8

Change – Scope & Extent

Time

Perfo

rman

ce

Developmental Change

Improvement of existing situation

Transitional Change

Implementation of a known new stateManagement of the interim transitionalState over a controlled period of time

Transformational Change

Emergence of a new state, unknownUntil it takes shape, often out of the deathOf the old state – time period not easilycontrolled

OldState

NewState

Birth

Growth

Plateau

Decay / Chaos

Death

Re-emergence

9

Prerequisites for successful change...and effects when one is missing!

1 2

3 4

1. Pressure for change2. Capacity for change3. A clear shared vision4. Actionable first steps

21

3

2

3 4

1

3 4

21

4

Bottom of ‘In-tray’ Anxiety & frustration Fast startfizzles out

Haphazard efforts& false starts

10

APATHY‘The world is alwayschanging’

AWARENESS ‘The NHSmust change’

AVOIDANCE ‘They must change’

RESISTANCE ‘We must change’

ACCEPTANCE ‘I must change’

INVOLVEMENT

DEGREE

OF

CHANGE

Reactions to Change

11

Communicating with different audiences [1]

20 – 25% Early AdoptersVery interested, willingly join

Communicating the change

20 – 25% Late AdoptersInterested but ... “Wait and see”

10 – 15% ChampionsAnd Pioneers

“Let’s get started!”

10 – 15% Active Resistors “Forget it!”

20 – 25% SkepticsWait and ... “I told you so!”

123

12

Communicating with different audiences [2]

123

1. Inform – Information organisation,prioritisation & presentation2. Construct an argument – Enlist support of [1] above3. Persuade and motivate – Maybe communicate costs of resistance

1. Early Adopters – Make/help it happen2. Late Adopters – Help/let it happen3. Skeptics – Let it/stop it happening

13

Communicating with different audiences [3]

Make it happen... Commitment – will make systems change to make it happen

Enrolment – will do whatever can be done within existing systems

Help it happen... Collaboration – Does everything expected and more

Compliance – Does what’s expected and no more

Let it happen... Benign apathy – Is it 5 o’clock yet?

Grudging compliance – Sees no benefit, wants no change. Not ‘on board’.

Against it happening... Non-compliance – ‘I won’t do it and you can’t make me!’

Sabotage – Propaganda, subterfuge or active hostility

LessMore

14

Communicating with different audiences [4]

Influencer Against it happening

Allow it to happen

Help it happen

Make it happen

1

2

3

4

15

Organisational learning

• Single-loop learning – Learning how to improve the status quo – 1st order incremental learning. The most prevalent form of organisational learning.

• Double-loop learning – Changing the conditions and assumptions within which single-loop learning takes place.

• Deutero-learning – Learning how to learn. Meta-learning, directed at the learning process itself. Improves both single and double loop learning.

16

Learning Quadrant

New Behaviour

Aware

Unaware

Old Behaviour

Unconscious Competence

Over-learning, faulty habits accumulate

Unconscious Incompetence

Old, faulty habits go unnoticed

Conscious Incompetence

Increased Arousal

Conscious Competence

Mindful Practice

17

Challenges for change facilitators...

Unconscious Incompetence

Conscious Incompetence

Conscious Competence

Unconscious Competence

T

A

T

A

T

A

T

A

Awareness

Accommodation

Assimilation

18

What’s the evidence?

What strategies are more or less effective in helping change the

practice of health care professionals?

19

Mostly effective (1)

Decision support (‘expert’) systems providing timely, relevant, evidence based information

e.g. computer ‘prompts’ that appear during a consultation (but computer systems can be cumbersome and produce impractical recommendations)

Locally produced and ‘owned’ protocolsi.e. locally relevant, locally derived, reflect local

priorities (outcomes are better when standards professionals are judged by are their own)

20

Mostly effective (2)

Interactive education

• Hands on methods structured around clinical problems

• Learning that clearly links the needs of the service with improved team working Mostly effective (1)

21

Sometimes effective

Audit and feedback, only when the health professional:

• Accepts that their practice needs to change• Has the resources and authority to implement

change• Feedback is offered in ‘real time’ – not

retrospectively

Client led strategies• Evidence based leaflets for clients

22

Largely Ineffective

Didactic education

Distribution of written guidelines, because:• They remain unread, misunderstood or

decontextualised• Lack of confidence in recommendations• Fear (of legal, client pressure, loss of income)• Lack of skill• Inadequate resources• Failure to remember (old habits die hard!)

23

Implementing Change – cautions from Ewan Ferlie and Louise Fitzgerald (1)

Finding one

• There is no strong relationship between the strength of the evidence and the rate of adoption of change

Implication

• Linear models of implementation are seriously misleading and are likely to lead to significant implementation problems

24

Implementing Change – cautions from Ewan Ferlie and Louise Fitzgerald (2)

Finding two

• Scientific evidence is in part a social construction as well as ‘objective data’

Implication

• There is no such entity as ‘the body of evidence’ but rather ‘competing bodies of evidence’

25

Implementing Change – cautions from Ewan Ferlie and Louise Fitzgerald (3)

Finding three

• There are different forms of evidence differentially accepted by different individuals and different groups

Implication

• Intergroup issues need to be addressed – different groups coming together in a learning environment outside of daily routine

26

Implementing Change – cautions from Ewan Ferlie and Louise Fitzgerald (4)

Finding four

• Specific organisational and social factors influence the path and outcome of change

Implication

• The most effective implementation strategies combine top-down pressure and bottom-up energy

27

Implementing Change – cautions from Ewan Ferlie and Louise Fitzgerald (5)

Finding five

• The upper tiers of NHS management, purchasers, R&D play a marginal role only in change process

Implication

• There is a need to acknowledge that change is embedded within the professions themselves

28

Evidence based change – the organisation as machine

Stage 1 – Formulation of answerable questions, demanding analytical skills, an awareness of gaps in knowledge and a compelling motivation to do something about them

Stage 2 – The search for the best evidence which requires selection of the most appropriate sources of information, their systematic investigation and the application of IT competencies to the full range of available data

Stage 3 – Critical appraisal of the evidence. Calling for rigorous scientific testing of the accuracy and diagnostic validity in the literature and data, with the help of statistical competencies and logical discrimination

Stage 4 – The decisions to apply the conclusions to patients healthcare, which demand the integration of the evidence and expertise to produce a soundly based judgement of treatment

The 4-stage framework (Sackett & Haines)

29

Experience based change – the organisation as complex system

• Enabling reflexivity within the system• Enabling the system to formulate a common

language for shared challenges• Enabling the system to value pluralism and

tension• Acknowledging that everybody has ‘part of the

truth’ and there are ‘many truths’• Not trying to reduce many views to one view• The process of identifying views is part of the

process of identifying a new, and perhaps shared, future

30